University of Dublin. Trinity College Dublin. School of Nursing and Midwifery. The National Infant Feeding Survey 2008

University of Dublin Trinity College Dublin School of Nursing and Midwifery The National Infant Feeding Survey 2008 Prepared for the Health Service Executive by: Professor Cecily Begley, Chair of Nursing and Midwifery Louise Gallagher, Doctoral Student/Midwifery Research Assistant Dr. Mike Clarke Adjunct Professor TCD and Director of UK Cochrane Centre Margaret Carroll, Director of Midwifery Sally Millar, Lecturer in Midwifery

Table of Contents Table of Contents...ii List of Tables... vii List of Figures...xii List of abbreviations...xiii Acknowledgements... xiv 1 Executive Summary... 15 1.1 Background and context for the study... 15 1.1.1 Introduction... 15 1.1.2 Literature review... 16 1.2 Methodology... 17 1.3 Quantitative results... 19 1.3.1 Phase 1 birth to 48 hours... 19 1.3.2 Phase 2 3-4 months... 19 1.3.3 Phase 3 6-7 months... 22 1.4 Qualitative findings... 22 1.5 Conclusion... 23 1.6 Recommendations... 23 2 Background and context of the study... 26 2.1 Introduction... 26 2.2 Aim... 27 2.3 Objectives... 28 2.4 Background to the National Infant Feeding Survey... 28 2.4.1 Definitions of breastfeeding... 29 2.5 Literature review... 31 2.5.1 Introduction... 31 2.5.2 Breastfeeding initiation and duration rates in Ireland... 31 2.5.3 Advantages of breastfeeding... 39 2.5.4 Factors affecting the decision to breastfeed... 40 3 Methodology... 45 3.1 Overview of study... 45

3.2 Ethical issues and access to study sites... 45 3.3 Survey design... 46 3.4 Questionnaire design... 46 3.5 Validity and reliability... 47 3.5.1 Validity... 47 3.5.2 Reliability... 48 3.6 Sample... 49 3.7 Data collection... 49 3.7.1 Data collection methods: Phase 1... 49 3.7.2 Data collection methods: Phase 2... 50 3.7.3 Data collection methods: Phase 3... 50 3.7.4 Maximising response rate... 50 3.8 Sample size achieved and response rates... 51 3.8.1 Phase 1... 51 3.8.2 Phase 2... 54 3.8.3 Phase 3... 54 3.9 Data analysis... 55 3.10 Focus groups... 56 3.10.1 Sample selection... 56 3.10.2 Instrument... 57 3.10.3 Conduct of focus group interviews... 57 3.10.4 Conduct of telephone interviews... 58 3.10.5 Data analysis... 58 4 Results of Phase 1... 60 4.1 Introduction... 60 4.2 Demographic results... 60 4.3 Intention to breast-feed... 62 4.4 The rate of exclusive and partial breastfeeding from birth to 48 hours... 62 4.5 Feeding method at 48 hours or on discharge... 63 5 Results of Phase 2 Demographics... 66 5.1 Introduction... 66 5.2 Sample profile... 66 5.3 Profile of the non-respondents... 69

5.4 Age of the babies at Phase 2 of the Survey... 70 5.5 Length of stay in hospital... 70 6 Results of Phase 2 Main findings... 71 6.1 Prevalence of breastfeeding... 71 6.1.1 Breastfeeding at three differing time points... 71 6.1.2 Effect of nationality on breastfeeding... 72 6.1.3 Prevalence of breastfeeding by hospital of birth... 75 6.1.4 Prevalence of breastfeeding by Local Health Office of residence... 78 6.1.5 Effect of ethnic origin of the mother on breastfeeding... 84 6.1.6 Effect of birth order on breastfeeding... 85 6.1.7 Effect of previous breastfeeding experience on breastfeeding... 87 6.2 Socio economic status and infant feeding... 88 6.3 Duration of breastfeeding... 91 6.4 Choice of feeding method... 92 6.4.1 Intended method of feeding... 92 6.4.2 Effect of age and education level on choice of feeding method... 94 6.4.3 Reasons for choice of feeding method... 98 6.5 Knowledge of the benefits of breastfeeding... 104 6.5.1 Knowledge of the benefits of breastfeeding to mothers... 104 6.5.2 Knowledge of the benefits of breastfeeding to infants... 106 6.6 Advice and information about infant feeding during pregnancy... 109 6.6.1 Information sources during pregnancy... 109 6.6.2 Attendance at ante-natal classes... 110 6.7 Factors related to planned feeding method... 111 6.7.1 Knowledge of breastfeeding among family and friends... 111 6.7.2 How mothers were fed themselves... 113 6.7.3 Ante-natal care... 114 6.8 Factors relating to birth, postnatal care and support... 114 6.8.1 Type of birth... 114 6.8.2 Type of pain relief... 116 6.8.3 Birth weight... 116 6.8.4 Skin to skin contact... 117 6.8.5 Length of stay... 117

6.8.6 Advertising... 118 6.8.7 Support and assistance with infant feeding... 118 6.8.8 Support services for breastfeeding mothers... 121 6.9 Use of pacifiers, food other than breast milk, and weaning practices... 124 6.9.1 Use of pacifiers... 124 6.9.2 Timing of introduction of formula... 124 6.9.3 Introduction of food other than breast milk or formula... 126 6.10 Challenges with infant feeding and infant health... 129 6.10.1 Admission to special or intensive care baby unit... 129 6.10.2 Problems encountered by infants... 130 6.10.3 Challenges related to breastfeeding... 134 6.10.4 Problems related to breastfeeding in the early days... 136 6.10.5 Feeding outside the home... 141 6.10.6 Barriers to mothers breastfeeding their infants in public... 144 6.10.7 Medications and breastfeeding... 145 6.11 Preferred length of breastfeeding... 146 6.11.1 Mothers views of breastfeeding duration... 146 6.11.2 Factors assisting mothers to continue or stop breastfeeding... 147 6.12 Mothers who were formula feeding from birth... 149 6.12.1 Sub group analysis - formula feeding women s views... 150 6.13 Future intentions... 163 7 Results of Phase 3 Main findings... 164 7.1 Prevalence of breastfeeding at six months... 165 7.1.1 Prevalence of exclusive and partial breastfeeding... 165 7.1.2 Prevalence of breastfeeding by Local Health Office of residence... 167 7.2 Use of supplementation and weaning... 175 7.2.1 Supplementation with formula milk... 175 7.2.2 Reasons for the introduction of formula while breastfeeding... 178 7.3 Challenges with infant feeding and infant health... 181 7.3.1 Infant health or feeding problems... 181 7.3.2 Challenges with breastfeeding... 182 7.3.3 Specific problems associated with breastfeeding since Phase 2... 184 7.3.4 Assistance with breastfeeding related problems... 185

7.4 Infant feeding and employment... 186 7.5 Preferred length of breastfeeding... 193 7.6 Support and assistance with infant feeding... 194 7.6.1 Support services used... 194 7.6.2 Support to continue breastfeeding... 196 7.7 Discontinuation of breastfeeding... 197 7.7.1 Reasons for discontinuing breastfeeding... 197 7.7.2 Age of infants when Phase 3 mothers discontinued breastfeeding... 200 7.7.3 Factors influencing discontinuation... 201 8 Discussion... 205 8.1 Introduction... 205 8.2 Limitations and success of the survey... 205 8.3 Breastfeeding rates... 206 8.3.1 Regional variations in breastfeeding rate... 207 8.3.2 Factors affecting initiation... 208 8.4 Duration of breastfeeding... 210 8.4.1 Impact of care... 211 8.4.2 Women s reasons for discontinuing... 213 8.5 Conclusion... 213 8.6 Recommendations... 214 9 References... 218 9.1 Appendix 1 Phase 1 Questionnaire... 229 9.2 Appendix 2 Phase 2 Questionnaire... 230 9.3 Appendix 3 - Phase 3 Questionnaire... 251 9.4 Appendix 4 Antenatal information leaflet... 261 9.5 Appendix 5 Reminder letter for Phase 2... 262 9.6 Appendix 6 Participant information leaflet... 263 9.7 Appendix 7 Consent form... 266 9.8 Appendix 8 Interview guide for focus groups... 268 9.9 Appendix 9 Consent form for telephone interviews... 269

List of Tables Table 1.1: A summary of the published Irish studies on initiation and duration from 1974-2008... 33 Table 2.1: Unit Codes and response rates for April... 53 Table 3.1: Mother s current age... 60 Table 3.2: Nationality of Phase 1 mothers... 61 Table 3.3: Age of Phase 1 mothers on completion of full-time education... 61 Table 3.4: Phase 1 babies in the special care baby unit or at another hospital... 61 Table 4.1: Planned type of feeding before the baby was born (Phase 1)... 62 Table 4.2: Type of food baby received for his/her first feed after birth (Phase 1)... 62 Table 4.3: Age of the baby at the first feed (Phase 1)... 63 Table 4.4: Proportion of women breastfeeding at first feed by Irish and Non-Irish (Phase 1)... 63 Table 4.5: Type of feeding on completion of Phase 1... 64 Table 4.6: How the mother was feeding at 48hrs (Phase 1)... 64 Table 4.7: Proportion of women breastfeeding today (i.e. question 5) at different ages (Phase 1)... 65 Table 5.1: Number of mothers having first or subsequent baby... 67 Table 5.2: Number of women having multiple births... 68 Table 5.3: Marital status of mothers... 68 Table 5.4: Employment status of mothers... 68 Table 5.5: (CSO) social classifications of mothers... 69 Table 6.1: Overall rate of breastfeeding at first feed, discharge from hospital and completion of phase 2... 72 Table 6.2: Nationalities of women... 72 Table 6.3: Prevalence of feeding type at birth, by nationality... 73 Table 6.4: Prevalence of feeding type at discharge by nationality... 74 Table 6.5: Type of feeding in last 7 days (Phase 2) by nationality... 74 Table 6.6: Breastfeeding numbers per hospital for first feed, at discharge and at 3 4.5 months... 76 Tables 6.7: Exclusive and partial breastfeeding for first feed, discharge and phase 2 by Health Service Executive Administrative Areas... 79

Tables 6.8 6.11: Exclusive and partial breastfeeding for first feed, at discharge and Phase 2 by Local Health Office... 80 Table 6.8: Health Service Executive: Dublin Mid-Leinster... 80 Table 6.9: Health Service Executive: Dublin North East... 81 Table 6.10: Health Service Executive: South... 82 Table 6.11: Health Service Executive: West... 83 Table 6.12: Ethnic origins of mothers in the overall sample... 84 Table 6.13: Type of first feed by ethnic origins of mothers in the overall sample... 85 Table 6.14: Feeding at birth by birth order... 86 Table 6.15: Feeding in the last week (Phase 2) for mothers who breastfed initially by first or subsequent baby... 86 Table 6.16: Feeding of previous infants for mothers with at least four other children87 Table 6.17: Feeding of previous infants for mothers with three other children... 87 Table 6.18: Feeding of previous infants for mothers with two other children... 88 Table 6.19: Feeding of firstborn infants for mothers with one other child... 88 Table 6.20: Feeding at birth by Social Class of mother... 89 Table 6.21: Feeding at 3-4 months for those who breastfed initially by social class of mother... 90 Table 7.1: Time at which breastfeeding mothers changed to full formula feeding... 91 Table 8.1: Mothers intention to feed before their infant was born... 92 Table 8.2: Mothers intention to feed before baby was born and type of first feed... 93 Table 8.3 Duration of any breastfeeding among mothers who breastfed at birth and how they planned to feed prior to birth... 94 Table 8.4: Age profile of the sample... 94 Table 8.5: Type of first feed after birth by age at which mother ceased full time education... 97 Table 8.6: Mothers highest level of education completed to date by type of first feed after birth... 98 Table 8.7: Breastfeeding mothers reasons for planning to breast-feed... 99 Table 8.8: Bottle-feeding mothers reasons for planning to bottle-feed... 100 Table 9.1: The benefits of breastfeeding for the respondent as a mother... 105 Table 9.2: The benefits of breastfeeding for the baby... 108 Table 10.1: Where mothers received advice on health benefits of breastfeeding... 110

Table 10.2: Type of first feed by whether the mother attended antenatal classes during pregnancy... 111 Table 11.1: How friends and family fed their children as infants... 112 Table 11.2: How mothers friends and family fed their children when they were babies by the kind of food babies received for their first feed after birth... 112 Table 11.3: How mothers were fed themselves as infants... 113 Table 12.1: Type of birth among sample... 115 Table 12.2: Type of birth and breastfeeding at discharge by among mothers who breastfed at birth... 115 Table 12.3: Weight of infants at birth... 116 Table 12.4: Type of first feed by the weight of infants at birth... 117 Table 12.5: Source of the most helpful information all mothers received about feeding since their baby was born... 119 Table 12.6: Support during the early postnatal period... 120 Table 12.7: Provision of information on breastfeeding support services... 121 Table 12.8: Ease of finding breastfeeding support services... 122 Table 12.9: Support services utilised... 123 Table 12.10: Satisfaction with support services... 123 Table 13.1 Time when breastfeeding mothers first introduced formula... 125 Table 13.2 Frequency of giving formula milk by breastfeeding mothers since birth 126 Table 13.3: Use of food other than breast milk or formula among all mothers... 126 Table 13.4: Proportion of mothers who give their baby something other than breast or formula milk by social classification of the mother... 128 Table 13.5: Proportion of mothers who give their baby something other than breast or formula milk by educational attainment of the mother... 129 Table 14.1: The most common reasons for admission to special or intensive care baby unit... 130 Table 14.2: Showing problems encountered by infants in the total sample by 3-4 months... 131 Table 14.3: Problems encountered by infants by feeding method at discharge from hospital... 132 Table 14.4: Problems encountered by infants based on feeding at 3-4 months for those who were breastfeeding at birth... 133

Table 14.5: Where breastfeeding mothers received help with feeding challenges in the early days following birth... 134 Table 14.6: Problems encountered as a result of breastfeeding... 135 Table 14.7: Problems encountered, if any, and type of feeding at 3-4 months... 136 Table 14.8: Problems reported related to early breastfeeding difficulties... 137 Table 15.1: Prevalence of feeding in public among mothers breastfeeding initially 141 Table 15.1: Mothers breastfeeding in public by highest education level achieved... 143 Table 15.2: Percentage of mothers breastfeeding in public by age of mother... 144 Table 15.3 Problems finding somewhere to breastfeed in a public place... 145 Table 16.1: Whether or not mothers would like to have breastfed for longer.... 146 Table 16.2: Breastfeeding mothers views on who or what helped them most to continue breastfeeding... 148 Table 16.3: Breastfeeding mothers views on who or what helped them least to continue breastfeeding... 148 16.4: Who or what influenced the mother to stop breastfeeding... 149 Table 17.1: Baby age in categories... 164 Table 18.1: Type of feeding at six months old... 165 Table 18.2: Milk and other fluids given to baby in the past 24 hours... 166 Table 18.3: Milk and other fluids given to baby in the past 7 days... 166 Table 18.4: Milk feeding at 6 months by nationality of the mother... 167 Table 18.5: Exclusive and partial breastfeeding at phase 3 (6 months) by Health Service Executive Administrative Areas... 168 Table 18.6: Health Service Executive: Dublin Mid-Leinster... 169 Table 18.6: Health Service Executive: Dublin Mid-Leinster Contd... 170 Table 18.7: Health Service Executive: Dublin North East... 171 Table 18.8: Health Service Executive: South... 172 Table 18.9: Health Service Executive: South Contd... 173 Table 19.1: How often mothers have given formula milks since they completed Phase 2... 175 Table 19.2: Age when baby was given any fluid other than breastmilk... 176 Table 19.3: Drinks given other than milk... 177 Table 19.4: Mother s reasons for giving infant formula... 178 Table 19.5: Problems encountered by babies... 182

Table 19.6: Number of women experiencing problems with breastfeeding since the last questionnaire... 183 Table 19.7: Problems encountered with breastfeeding since Phase 2... 183 Table 19.8: Problems experienced since Phase 2... 185 Table 19.9: People who helped mothers with problems... 186 Table 20.1: Employment status in main job... 187 Table 20.2: In paid work at Phase 3... 187 Table 20.3: Type of feeding at 6 months and mother s current employment status. 188 Table 20.4: Number of hours worked per week... 188 Table 20.5: Age of infants when mothers returned to work... 189 Table 20.6: Type of feeding at Phase 3 by number of hours the mother is working 189 Table 20.7: Type of feeding by age of baby when mother returned to work... 190 Table 20.8: Provision of facilities by employers to express or breastfeed... 190 Table 20.9: Type of feeding by availability of facilities to express or breastfeed at work... 191 Table 20.10: How baby is cared for while mother is at work... 192 Table 20.11: Mother s plans to start work again within the next year... 192 Table 20.12: Type of feeding by mother s plans to work in the next year... 193 Table 21.1: Duration of breastfeeding in relation to previous intention... 194 Table 21.2: Breastfeeding support services used... 194 Table 21.3: Ease of finding breastfeeding support services... 195 Table 21.4: Information on how to get help with feeding since the last questionnaire... 195 Table 21.5: Source of the most helpful information mothers received about feeding since the baby was born... 196 Table 21.6: Factors or people that helped mothers most to continue breastfeeding. 197 Table 21.6: Breastfeeding mothers reasons for stopping breastfeeding... 198 Table 21.7: Age of infants when they were last given breastmilk or breastfed... 201 Table 21.8: Factors or people that influenced mothers who have discontinued to stop breastfeeding... 202 Table 21.9: Factors that would have assisted mothers to continue breastfeeding... 202

List of Figures Figure 1:... 55 Figure 2: Feeding at birth by Social Class of mother... 89 Figure 3: Type of first feed by age of the mother... 95 Figure 4: Type of feeding at 3-4 months for those who started breastfeeding by age of the mother... 96 Figure 5: Feeding at birth by how friends and family feed their infants.... 113 Figure 6: How the mother was fed herself by feeding method at birth... 114 Figure 7: Rates of combination feeding by day of discharge from hospital... 118 Figure 8: Type of feeding at discharge and whether the mother has introduced solids or fluids other than breast milk or formula at Phase 2... 127 Figure 9: Percentage of mother s breastfeeding in public by ethnic group... 141 Figure 10: Percentage of mothers breastfeeding in public by highest education level achieved... 142 Figure 11: Percentage of mothers breastfeeding in public by age of mother... 144 Figure 12: Age of the baby at which the mother stopped breastfeeding and whether she would have liked to continue for longer... 147

List of abbreviations CSO: Central Statistics Office DOH&C: Department of Health and Children EBM: Expressed breast milk ESRI: Economic and Social Research Institute NPRS: National Perinatal Reporting System EU: European Union GP: General Practitioner HSE: Health Service Executive PHN: Public Health Nurse FSAI: Food Safety Authority of Ireland WHO: World Health Organisation UNICEF: United Nations Children s Fund

Acknowledgements We are grateful to the women who consented to join this study and who gave so generously of their time in completing questionnaires and joining in focus groups. We thank all the Directors of Midwifery who assisted us with access for the study and the midwives across the country who gave their support through providing information to women. Advice and guidance was also received from Maureen Fallon in the Health Service Executive, which was much appreciated. Finally, our thanks go to the Health Service Executive, who commissioned the study.

1 Executive Summary 1.1 Background and context for the study 1.1.1 Introduction The Department of Health and Children published Breastfeeding in Ireland: A Five Year Strategic Action Plan for Breastfeeding in October 2005 (Department of Health and Children (DOH&C) 2005). This action plan aims to improve the nation s health and wellbeing by ensuring that breastfeeding becomes the norm for infants and young children. Two key targets for Ireland are to raise the breastfeeding initiation and duration rates by two percentage points per year overall and to increase the breastfeeding rate by 4% per year for families from socio economic groups 5 and 6 (DOH&C 2005). In Ireland, there is no comprehensive, reliable national source of infant feeding data following discharge from hospital or maternity care, which makes it difficult to measure progress against the targets for the duration of breastfeeding. Efforts are being made to support the roll-out of the Personal Held Record (PHR) system (currently used in 6 out of 32 Local Health Office areas) as this has the potential to generate accurate, timely infant and young child feeding data nationally at multiple stages throughout early childhood. Improvements in the comprehensiveness and accuracy of the HSE infant feeding Performance Indicators (PIs) could also generate reliable breastfeeding duration rate data. To address the deficit in data that currently applies, the Health Service Executive (HSE) commissioned a three-phase study to examine infant feeding in Ireland to determine the rate and duration of breastfeeding, the factors influencing women to breastfeed and the reasons given by women for stopping breastfeeding. Phase 1 elicited baseline data on the rate of exclusive and partial breastfeeding from birth to 48 hours, Phase 2 provided data at 3-4 months following birth, and Phase 3 obtained information on the rate of breastfeeding when the infant was 6-7 months old. Subgroup analyses were conducted at the level of individual maternity 15

hospital/unit/independent midwife, socio-economic group, nationality and Health Service Executive, Local Health Office (LHO). In addition, qualitative focus group research was conducted with groups of mothers who were least likely to breastfeed in Ireland. 1.1.2 Literature review A comprehensive review of the literature was undertaken, which showed that there was evidence of a steep decline in Irish breastfeeding rates from 64% in the 1950s to 16% by 1975 (Kevany et al 1975). In the 1980s and 1990s, a series of studies commissioned by the Health Education Bureau (O'Herlihy 1978, McSweeney & Kevany 1982, McSweeney 1986), followed by the commencement of national gathering of perinatal statistics by the Department of Health (ESRI 1991-2007) demonstrated that, from 1981 to 1990, the national incidence of breastfeeding on leaving hospital was 30-35%. In 1992, the Euro-Growth study confirmed that Irish breastfeeding initiation rates were the lowest in Europe (Freeman 1996). Perinatal statistics show a recent increasing trend in the breastfeeding rate from 36% in 1999 to 44% in 2005 (ESRI 2008); however, this trend may be more influenced by the collection methods than the reality of breastfeeding in Ireland. To date there has been no uniform or comprehensive system of collating data relating to breastfeeding at birth, or in the longer postnatal period. Breastfeeding is associated with many advantages (Kramer and Kakuma 2002) such as fewer gastrointestinal, respiratory, aural and urinary tract infections and fewer atopic illnesses. It has been consistently shown to reduce mortality among preterm infants (Lucas and Cole 1990, Lucas et al 1998, Vohr et al 2006) and may offer some protection against the development of early onset insulin dependant diabetes mellitus (Virtanen et al 1991), type 2 diabetes (Owen et al 2006), raised adult blood pressure (Singhal et al 2001) and obesity (Fewtrell 2004, Harder et al 2005). For mothers, breastfeeding leads to a lower incidence of premenopausal breast cancer, (Enger et al 1997, Beral et al 2002), ovarian cancer (Rosenblatt & Thomas 1993) and osteoporosis (Cummings & Klineberg 1993), and a faster return to pre-pregnancy weight (Dewey et al 1995). 16

Factors positively associated with breastfeeding initiation in developed countries include higher socio-economic group, increased age and greater education (Dyson et al 2005, Gudnadottir et al 2006). Women from non-white ethnic groups are also more likely to breastfeed (Tarrant 2008). The employment status of women and whether or not they themselves were breastfed (Fitzpatrick et al 1994, Ward et al 2004) may also affect initiation rates. The review for this survey highlighted that the rate of breastfeeding in Ireland has fallen short of the World Health Organisation (WHO) and UNICEF recommendations that infants should be exclusively breastfed for six months, and that 98% of women are capable of doing so (WHO 1999). National and regional studies also showed that very few Irish women who initiate breastfeeding continue to breastfeed exclusively for the recommended six months, or continue to breastfeed thereafter in combination with complementary foods up to the recommended two years of age or beyond. The review of the literature clearly highlighted the need to obtain up-to-date, accurate breastfeeding initiation and duration rates in a nationally representative sample of mothers in Ireland. 1.2 Methodology Ethical approval for this study was granted by the Research Ethics Committee of the Faculty of Health Sciences in Trinity College Dublin. Local ethical approval and access was also granted from all hospitals involved. Phase 1 of data collection involved a survey of infant feeding practices at discharge from hospital/unit/independent midwife, or at 48 hours if the woman had not been discharged by that time. The survey instrument for Phase 1 was kept short to maximise the response rate and minimise the amount of time it would take to fill out the questionnaire. Women who gave birth to live babies at 24 weeks gestation or greater in the 20 maternity hospitals/units (or under the care of the 19 independent midwives) in the Republic of Ireland during the month of April 2008 were asked to take part. Women who gave birth to a stillborn baby or whose baby died within the 17

first 48 hours during the study period were excluded. In Phase 1, 2,527 women took part, which represents a 33% response rate for all births in the month of April 2009. Phase 2 (at 2-3 months postnatal), consisted of a postal survey of all women who completed Phase 1 of this study, of whom 72% (1,826) responded. A postal survey was also employed during Phase 3 (6-7 months postnatal), for those mothers (n=621) who indicated that they were breastfeeding when they completed Phase 2. Of these, 461 women responded, representing a 74% response rate. The questionnaires for all three phases of the study were derived from a well-tested survey instrument used in the United Kingdom over several decades (Bolling et al 2006). The final questionnaires were pre-tested for face and content validity and reliability, and translated into Polish, Latvian, Lithuanian, Irish, French and Portuguese as necessary. Two small focus groups, with 2 women in each, and 6 telephone interviews were conducted with women in lower socio-economic groups, to ascertain factors that may encourage these women to breastfeed in the future. The quantitative data from all phases were analysed using The Statistical Package for the Social Sciences (SPSS) Version 15 (SPSS 2006, Chicago, IL). Sample characteristics are described using percentages, means or medians and standard deviations and comparative analyses were carried out using chi-square analysis. The level of statistical significance was accepted at 0.05. Thematic analysis of qualitative data took place through reading and rereading of the transcriptions, coding, categorisation and development of themes. The themes were then grouped into dimensions and perspectives. Constant comparative analysis was performed to construct the categories and concepts, and theoretical sampling of women was undertaken in the telephone interviews as the core categories emerged. 18

1.3 Quantitative results 1.3.1 Phase 1 birth to 48 hours The mean age of the women was 31.3 years (S.D = 5.6 years), and almost equal numbers (45% in each group) had completed their education by 19 years or between that age and 24 years. Fifty-five percent (n=1,375) of women put the baby to the breast initially after birth. For 68% (n=935) of babies, this first feed took place within one hour of birth. Only 50% of Irish women (n=1,010), compared with 76% (n=365) of non-irish women, initiated breastfeeding. The highest breastfeeding initiation rate was in Dublin South East (78%) and the lowest rate was in Waterford and Louth (38%). Mothers who were having their first baby were more likely to breast than bottle feed (60%, n=433) and the majority of mothers having their second or subsequent baby also breastfed at birth (54%, n=567). Professional, managerial and technical workers were more likely to initiate breastfeeding (70% and 69% respectively) than those in non-manual, semi-skilled, skilled or manual employment (37-51%). The most frequent problems encountered by women in the early days of breastfeeding were difficulty in getting their baby latched on to the breast (n=230, 38% of those reporting a problem) and problems with their nipples (n=177, 29%). By 48 hours (or on discharge, if that was earlier), 42% (n=1,064) of women were exclusively breastfeeding their babies, with a further 13% (n=307) breast and bottle feeding. Waterford had the lowest rate of exclusive breastfeeding at discharge, at 29%, while Dublin areas had above average rates (47-65%). 1.3.2 Phase 2 3-4 months At Phase 2, 19% (n=347) of women were exclusively breastfeeding their babies, with a further 15% (n=274) partially breastfeeding. Sligo/Leitrim had the lowest level of exclusive breastfeeding at 3-4 months (12%). 19

Mothers were asked why they thought they might feed their infant by the chosen method and 978 women who breastfed at birth gave 2,063 responses (average of 2.11 responses each). The main reasons were that it was best for baby (86% of women who answered this question), they had breastfed before (27%), it was more convenient (25%), it increased mother-baby bonding (21%) and had benefits for the mother (20%). Of the women who bottle-fed at birth, 720 replied and gave 723 responses (average of 1 response each). Their main reasons for choosing bottle-feeding were that they had bottle-fed before (29% of women who answered this question), they were not comfortable with breastfeeding (19%), their husband could help (11%), they had other children (9%) or they were unsuccessful at breastfeeding before (9%). Participants were also asked to list the benefits of breastfeeding. Those responders who breastfed (n=836) provided 1,697 benefits of breastfeeding (average of 2.03 per person), while the 449 women who bottle-fed listed 740 benefits (average of 1.65 benefits per mother). Infant feeding was not discussed with 31% (n=550) of women during pregnancy. Those who were given information received it mainly from a midwife (66% n=824) and general practitioner (31% n=378). Breastfeeding was initiated by 62% (n=449) of mothers who attended antenatal classes compared to 52% (n=546) initiation among those who did not attend classes. Those mothers who said that most of their friends breastfed their babies were more likely to breastfeed at birth (n=252, 79%) than those whose friends and family used formula feeding (n=384, 47%). Mothers who were breastfed as infants were more likely to initiate breastfeeding at birth (n=441, 76%) than those who were formula fed (n=1,293, 50%) or did not know how they were fed (n=73, 45%). Women who had a Caesarean section were more likely to have discontinued breastfeeding at discharge (13%) than those who had a normal birth (8%). Information on how to get help with infant feeding was provided on discharge to 88% of breastfeeding mothers but only 58% of formula feeding mothers. Among mothers who were breastfeeding from birth, 81% (n=754) were shown how to put the baby to the breast during the first few days. Only 3% (n=25) of mothers reported that someone stayed with them for a whole feed, while 58% (n=431) reported that 20

someone returned to check on them during the feed and 35% (n=262) of mothers reported that they had assistance for the beginning of a feed only. Regarding the use of a dummy or soother, 64% (n=1176) of infants were using one at 3-4 months and, of these, 70% had been given a soother by 3 weeks (n=833). Soother use was associated with discontinuation of breastfeeding before 3-4 months, with 74% (n=342) of those switching to fully formula feeding using a soother compared to 37% (n=130) of those still exclusively breastfeeding. Only 219 women (26%) reported that they had never given their baby infant formula by 3-4 months old and a further 9% (n=76) had given formula milk only once or twice since birth. Women who formula fed at birth (n=437, 58%) were more likely to give additional foods to their babies at 3-4 months than those who exclusively breastfed (n=285, 32 %). Women from lower socio-economic categories and those with lower educational attainments were more likely to have given additional foods to their babies. Of the babies breastfeeding at discharge, 33% had never been ill by 3-4 months, compared with 27% of formula-fed babies and 25% of those who combined breast and formula feeding. Of those babies who were still exclusively breastfeeding at 3-4 months, 39% had never been ill. By 3-4 months just over half of the mothers who were breastfeeding initially had breastfed in public (n=487, 53%). Of the mothers who breastfed initially, 44% said that they breastfed for as long as they intended (n=396) and 45% said that they would like to have breastfed for longer (n=404). Among those mothers who had switched to fully formula feeding at 3-4 months, 81% (n=359) said that would like to have breastfed for longer. Only 38% (n=251) of mothers who were formula feeding from birth had been shown how to make up a formula feed, 54% (n=133) by a midwife, 29% (n=72) by a family member and 17% (n=43) by a public health nurse. 21

1.3.3 Phase 3 6-7 months At Phase 3, exclusive breastfeeding was reported by 18% (n=61) of the 461 mothers who were breastfeeding at Phase 2, which is 10% of the 621 who were either exclusively or partially breastfeeding their babies at Phase 2, 6% of the 1002 mothers who had breastfed their infants at birth and responded to Phase 2, and only 2.4% of the 2,527 mothers who took part in Phase 1. A further 230 mothers were partially breastfeeding at six months, which is 37% of the 621 who were either exclusively or partially breastfeeding their babies at Phase 2, 23% of the 1002 mothers who had breastfed their infants at birth and responded to Phase 2, and only 9% of the 2,527 mothers who took part in Phase 1. The highest rate was in Wicklow, with 13% (n=7) of the 92 mothers from this area reporting exclusive breastfeeding at 6-7 months. Of the women who responded to Phase 3 and had been breastfeeding at Phase 2, 108 mothers (24%) would have liked to have breastfed for longer. The majority discontinued due to their busy lifestyle (n=48, 25%), perceived insufficient milk supply (n=39, 20%) or lack of facilities/uncomfortable with feeding in public (n=33, 17%). 1.4 Qualitative findings The findings from the qualitative aspect of the study suggest that formula feeding women base their infant feeding decision on many social and experiential factors. Dominant themes indicated that the major influences on infant feeding for these women were: Personal attitudes toward feeding methods, external influences on infant feeding methods. Attitudes towards other mothers and feeding future infants also reinforced a strong preferences towards formula feeding. It is apparent that a prevailing culture that is unreceptive to breastfeeding and the lack of positive breastfeeding role models, contributed to a strong commitment to formula feeding. 22

1.5 Conclusion The results clearly highlight that the overall rate of breastfeeding is increasing in Ireland but remains low in comparison with other countries. The low rate of exclusive or even partial breastfeeding at six months indicates that very few women and infants in Ireland are receiving the benefits of breastfeeding for the duration recommended by the World Health Organisation (2001). The findings from the interviews with women in lower socio-economic groups demonstrated that artificial formula feeding women would require positive breastfeeding role models to counter the many negative breastfeeding influences on them, if they were to consider it for future children. Health professionals also need to promote and support breastfeeding for all mothers and not make assumptions about women s intentions or expectations based on their previous infant feeding methods. 1.6 Recommendations The findings of this research survey strongly support the prompt and full implementation of the 5 Year Strategic Action Plan for Breastfeeding (DOH&C, Oct. 2005). This Action Plan addresses virtually all of the policy and practice deficits identified in the Survey, including the following recommendations: Target promotion and support services to improve breastfeeding up-take and duration for women in communities with currently very low rates (Actions 5, 21, 23). Broaden the promotion of breastfeeding to a whole population societal level to include school children of all ages, both girls and boys and especially teenagers, as well as pregnant and postnatal women, their partners and families (Actions 6, 22, 30, 31, 40, 41, 42, 43, 44). Promote positive breastfeeding portrayals and providing objective expert information and support within schools, the media and in antenatal education programmes, thus assisting future and expectant parents to make informed infant feeding decisions (Actions 1, 6, 22, 40, 41, 42, 43). 23

Implement the WHO/UNICEF Baby Friendly Initiative (BFI) at hospital and community health levels nationally as proposed by the Action Plan (Actions 8, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20) as this would address many of the health service practices known to adversely affect the success of breastfeeding initiation (eg. the routine supplementation of breastfed babies with formula or other fluids and the separation of mothers and babies etc). Provide extra hospital outreach or community-based support and assistance for breastfeeding mothers in the first two weeks post discharge to improve continuation rates (Actions 7, 19). To try and address the pattern of very early cessation of breastfeeding identified in the survey findings, ensure that the first support visit of the public health nurse takes place within the first 24-48 hours following discharge from hospital. Identify and address the specific needs of mothers who have undergone caesarean section or other forms of instrumental birth or who have given birth prematurely (Actions 14, 18, 26). Provide information on local statutory and voluntary community breastfeeding support services available to mothers on discharge from maternity care and establishing breastfeeding support groups where these are not available (Actions 2, 3, 4, 5, 6, 7, 12, 15). Organise national campaigns highlighting the availability of expert statutory and voluntary sources of breastfeeding information and support and how to access these (Actions 2, 4, 7, 22, 40). Provide for the information needs of mothers who are formula feeding prior to discharge from maternity care (Action 7). Provide comprehensive additional, timely community breastfeeding support services on a 7 day/week basis to counter the sharp decline in breastfeeding during the early weeks and months following discharge from maternity care (Actions 2, 3, 4, 5, 7, 12, 13, 15, 19). Encourage and incentivise public service providers (eg. hotels, restaurants, cinemas etc) and employers to welcome breastfeeding clients/employees to their premises/workplaces and provide separate designated feeding rooms for 24

mothers who want/need more privacy when feeding or expressing (Actions 30, 31, 38, 39). Prioritise the establishment of a national child health information system that is capable of generating infant and young child feeding data that is comprehensive, timely, reliable and accurate, for example, by funding the national roll out of the PHR system (Actions 25, 26 ). Until a suitable national data collection system is in place to audit the targets set in the Strategy, a survey similar to the National Infant Survey should be repeated every 2 years to evaluate progress. Educate health professionals on the effect of caesarean and instrumental birth on breastfeeding and the need for additional support for these women (Actions 16, 17, 18). Educate health professionals on how best to promote and support breastfeeding for women with the lowest rates of breastfeeding initiation and continuation (Actions 16, 17, 18). 1 Further research Further research is needed to understand more fully how and when infant feeding decisions are made and what or who the major influencers on these decisions are (Action 10, 23). Future surveys are needed to examine the effect negative attitudes to breastfeeding in Ireland are having on the infant feeding practices of newly arrived families from cultures where breastfeeding is the norm (Action 10, 23). Education programmes for health professionals, and new initiatives to support women to breastfeed for longer need to be introduced and evaluated through research (Actions 10, 16, 17, 37). 1 The Action Plan is available to view or download at: www.breastfeeding.ie/strategy 25

2 Background and context of the study 2.1 Introduction The established health benefits of breastfeeding have resulted in global and national initiatives to support and promote the commencement and continuation of breastfeeding. In 2003, the World Health Organisation recommended that, wherever possible, infants should be fed exclusively on breast milk until six months of age and continue being breastfed thereafter in combination with suitably nutritious complementary foods to receive the maximum health benefits (World Health Organisation (WHO) 2003). However, initiation rates for breastfeeding in Ireland continue to be among the lowest in Europe (Department of Health and Children (DOH&C) 2005). Hospital discharge data from the 2005 National Perinatal Reporting System (NPRS) reveal a breastfeeding initiation rate of 47.5% (Economic and Social Research Institute (ESRI) 2008). Although this had risen from 31% in 1991, it compares poorly with other European countries. Rates of up to 99% have been reported in Norway (Lande et al 2003), 97% in Switzerland (Merten and Ackermann- Liebrich 2004), 83% in Italy (Banderali et al 2003) and 78% in England (Bolling et al 2006). In Ireland, initiation rates were found to be even lower in some groups: about one third for mothers in lower socio-economic groups (ESRI 2008). Futhermore, the health protective benefits of breastfeeding in early infancy have been shown to be maximised with six months of exclusive breastfeeding, however, the vast majority of infants in Ireland are being denied full advantage of these health benefits (Tarrant 2008). Prior to this study, the NPRS breastfeeding figures were the only national data currently available on infant feeding in Ireland, but there is a 2-3 year time lag between collection and availability of data from this source (DOH&C 2005). The Department of Health and Children published Breastfeeding in Ireland: A Five Year Strategic Action Plan for Breastfeeding in October 2005 (DOH&C 2005). This action plan aims to improve the nation s health by ensuring that breastfeeding once again becomes the norm for infants and young children in Ireland (DOH&C 2005). The plan contains two key targets for Ireland: to raise the breastfeeding initiation and duration rates by two percentage points per year and to increase the breastfeeding rate 26

by 4% per year for families from socio economic groups 5 and 6 (DOH&C 2005). These are national targets, but they are also applicable at the level of individual maternity hospitals and units, as well as at local health office (LHO) level. Although a consistent strategy of recording breastfeeding rates over time has been shown to measure the prevalence and duration of breastfeeding effectively (Sheehan et al 2001), there has been no national source of infant feeding data following discharge from hospital or maternity care. This makes it difficult to measure progress against the targets for the duration of breastfeeding, because existing sources of data are either not collected on a sufficiently widespread basis (eg. the personal health record (PHR), child health recording system collects these data, but it only applies in 6 out of the 32 LHOs nationally) or do not provide sufficiently comprehensive, accurate or timely data for national evaluation (DOH&C 2005). National breastfeeding surveys have been conducted elsewhere and these have helped to shape national policies and strategies to improve breastfeeding rates in those countries (Hofvander 2003, Bolling et al 2006). To address this deficit, the Health Service Executive (HSE) commissioned a threephase study to examine infant feeding in Ireland to determine the rate of breastfeeding and the factors influencing women to breastfeed here. Phase 1 elicited data at birth, Phase 2 provides baseline data on the rate of exclusive and partial breastfeeding at 3-4 months following birth, ascertains what factors influence a decision to breastfeed or not and determines the reasons given by women for stopping breastfeeding prior to this stage. Phase 3 obtains information on the rate of breastfeeding at 6-7 months old. 2.2 Aim To examine infant feeding in Ireland to determine the rate and duration of breastfeeding and the factors influencing women to breastfeed. 27

2.3 Objectives To provide baseline data on the rate of exclusive and partial breastfeeding from birth to 48 hours, at 3-4 months and at 6-7 months following birth. To ascertain what factors influence a woman s decision to breastfeed or not. To ascertain the reasons given by women for stopping breastfeeding at all stages. To conduct sub-group analyses at the level of individual maternity hospital/unit/independent midwife, socio-economic group, nationality and Health Service Executive, Local Health Office (LHO). To provide data that will be internationally comparable by, inter alia, using best evidence based definitions and research methodologies. To establish a valid and reliable survey tool and protocol to enable replication in the future. To conduct sub-group qualitative focus group research with mothers who are least likely to breastfeed in Ireland (eg. mothers from low socio-economic groups), and mothers from ethnic minorities. To make evidence-based recommendations to assist the Health Service Executive and individual healthcare providers in the planning and provision of more effective services to increase the rate of breastfeeding in Ireland. 2.4 Background to the National Infant Feeding Survey In 1994, the Department of Health (DOH 1994) published the first national breastfeeding policy for Ireland. This was followed by the establishment of a National Committee on Breastfeeding in 2002. In 2005, following an extensive consultation process, this committee published a Five Year Strategic Action Plan, which identifies 28

goals, objectives and actions to improve breastfeeding rates and practices in Ireland. The national survey reported here fulfils an important element of the Action Plan, in that it provides national data on the prevalence and duration of exclusive breastfeeding, thereby establishing a baseline for the on-going monitoring of key targets. In addition, the survey establishes the factors influencing the infant feeding decisions of women in Ireland, the reasons they start and the reasons they stop breastfeeding. This knowledge will support the continuing development of national and, more importantly, local strategies to address the rates of breastfeeding initiation and duration in Ireland at both national and local level. It will help target effective interventions where they are found to be most required. High quality data relating to breastfeeding in Ireland is imperative in order to understand the unique cultural, social, psychological and environmental factors influencing infant feeding choices in this country. An understanding of these is vital if the health and nutritional needs of women, infants and young children are to be optimally met. Therefore, this infant feeding survey aimed to establish accurate baseline data for the purposes of evaluating the targets set in the Strategic Action Plan (DOH&C 2005), and provide a mechanism for evaluating progress into the future, using the validated survey tool developed. 2.4.1 Definitions of breastfeeding The agreed definitions of the WHO (2003) relevant to breastfeeding are: Breastfeeding: expressed) The child has received breast milk (direct from the breast or Exclusive breastfeeding: The infant has received only breast milk from his/her mother or a wet nurse, or expressed breast milk, and no other liquids or solids with the exception of drops or syrups consisting of vitamins, mineral supplements or medicines Predominant breastfeeding: The infant s predominant source of nourishment has been breast milk. However, the infant may also have received water and/or waterbased drinks (sweetened and flavoured water, teas, infusions etc.); fruit juice; oral 29

rehydration salts; drops and syrup forms of vitamins, minerals and medicines; and ritual fluids (in limited quantities). With the exception of fruit juice and sugar-water, no food-based fluid is allowed under this definition. Predominant breastfeeding and exclusive breastfeeding together constitute full breastfeeding. Artificial feeding: Feeding an infant on breast-milk substitute. Bottle-feeding: Feeding an infant from a bottle, whatever is in the bottle, including expressed breast milk, water, formula, etc. Complementary feeding: The child is receiving both breast milk and solid (or semisolid) food. One further definition has been added, documented by the WHO in 2001 as follows: Partial breastfeeding: The infant receives some breastfeeds, and some artificial feeds, either milk or cereal or other foods (WHO/EURO 2001). The Five Year Strategic Action Plan (DOH&C 2005) endorsed the WHO definitions of exclusive (WHO 2003) and partial (WHO 2001) breastfeeding as those to be applied in assigning targets related to breastfeeding duration in Ireland and these are applied in this report. 30